Medical care research and review : MCRR
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Team-based care involving physician assistants and/or nurse practitioners (PA/NPs) in the patient-centered medical home is one approach to improving care quality. However, little is known about how to incorporate PA/NPs into primary care teams. Using data from a large physician group, we describe the division of patients and services (e.g., acute, chronic, preventive, other) between primary care providers for older diabetes patients on panels with varying levels of PA/NP involvement (i.e., no role, supplemental provider, or usual provider of care). ⋯ Patients with physician usual providers had similar probabilities of visits with supplemental PA/NPs and physicians for all service types. However, patients with PA/NP usual providers had higher probabilities of visits with a supplemental physician. Understanding how patients and services are divided between PA/NPs and physicians will assist in defining provider roles on primary care teams.
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Patient-centered care (PCC) has been studied for several decades. Yet a clear definition of PCC is lacking, as is an understanding of how specific PCC processes relate to patient outcomes. We conducted a systematic review of the PCC literature to examine the evidence for PCC and outcomes. ⋯ There was stronger evidence for positive influences of PCC on satisfaction and self-management. Future research should examine specific dimensions of PCC and how they relate to technical care quality, particularly some dimensions that have not been studied extensively. Future research also should identify moderating and mediating variables in the PPC-outcomes relationship.
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There were more than 19 million hospitalizations in 2008 from hospital-based emergency departments (EDs), representing nearly 50% of all U. S. admissions. Factors related to variation in hospital-level ED admission rates are unknown. ⋯ In 1,376 EDs, the mean ED admission rate, when defined as direct admissions and also transfers from one ED to another hospital, was 17.5% and varied from 9.8% to 25.8% at the 10th and 90th percentiles. Higher proportions of Medicare and uninsured patients, more inpatient beds, lower ED volumes, for-profit ownership, trauma center status, and higher hospital occupancy rates were associated with higher ED admission rates. Also, hospitals in counties with fewer primary care physicians per capita and higher county-level ED admission rates had higher ED admission rates.
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Patient involvement in decisions is central to patient-centered care. Yet many important decisions must be made in complex, ambiguous clinical situations in which all possible options cannot be known, evidence is inadequate to inform patients' preferences fully, and/or patients are unclear about their desired level of involvement. ⋯ Clinical and interpersonal relationships can promote effective decision making through developing a shared attentional focus, tailoring information, and identifying conditions under which provisional preferences might change. Information technology and health systems offer untapped potential to deepen the relationships and conversations within which decisions are made.
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This article evaluates the accuracy of reporting do not resuscitate (DNR) orders in administrative data for use in risk-adjusted hospital assessments. We compared DNR reporting by 48 California hospitals in 2005 patient discharge data (PDD) with gold-standard assessments made by registered nurses (RNs) who reabstracted 1,673 records of patients with myocardial infarction, pneumonia, or heart failure. ⋯ The administrative data did not reflect a DNR order in 71 of 512 records where the RN indicated there was (14% false negative rates), and reflected a DNR order in 191 of 1,161 records where the RN indicated there was not (16% false positive rate). The accuracy of DNR was more problematic for patients who died, suggesting that hospital-reported DNR is problematic for capturing patient preferences for resuscitation that can be used for risk-adjusted outcomes assessments.